This small study looked at a form of surgery called deep brain stimulation, which involves implanting electrodes in the brain, to see if it helped with tremor. Deep brain stimulation worked well for some people but not at all for others. Tremor was reduced, on average, by just over a third (39%) but the range was from zero to 87%. For those people who responded to treatment, there was an improved quality of life and ability to carry out every day tasks.
Tremor is an unintentional, rhythmical, shaking movement of the body, often most obvious in the arm or hand. There are different kinds of tremor. In MS, the most common is intention tremor – this is a tremor that gets worse as someone reaches forward for an object, such as when reaching forward to pick up a cup or when placing the cup to the mouth. Some people experience postural tremor, which occurs when a person is maintaining a posture against gravity, such as sitting up. You can watch a video (1 min 20 sec) from the National MS Society (in America) which shows the different kinds of tremor.
Tremor can occur gradually or can appear rapidly. It may occur in one arm only but frequently occurs in both. Living with tremor can be both frustrating and fatiguing and can contribute to disability and poor quality of life.
How this study was carried out
This small study looked at a surgical technique called deep brain stimulation (DBS) and, in particular, a form called ventral intermediate (VIM) nucleus DBS, for the treatment of tremor. Deep brain stimulation involves permanently implanting electrodes in selected parts of the brain. The electrodes are connected to an implanted pulse generator which is battery powered. The electrical pulses are thought to block the nerve impulses that cause tremor.
16 people with MS (9 women and 7 men) with an average age of 42 (the range was from 24 to 59) underwent surgery. On average, the participants had been diagnosed with MS for seven years and had experienced tremor for four years.
Two of the group had an electrode inserted in one side of the brain but the other 14 participants had electrodes inserted in both sides of the brain. A local anaesthetic was used so that the health professionals could check that the electrodes were located in a suitable place and were working. This was done by asking the person to do postural and pointing exercises and assessing how well these could be performed.
Quality of life and the amount of tremor was assessed before the operation and at six and 12 months afterwards. At a follow up clinic after surgery, the stimulation of the electrodes could be adjusted as often as needed to get the maximum benefit.
What was found
Deep brain stimulation worked well for some people but not at all for others. Tremor was reduced, on average, by over a third (39%) but the range was from zero to 87%. 11 people had at least a 30% reduction in their tremor after an average of 12 months and five of these had at least a 50% reduction.
The improvement in tremor corresponded with improved abilities in feeding, hygiene, dressing, writing and working. Quality of life also improved especially in the group who experienced the greatest reduction in tremor.
What does it mean?
The authors concluded that this form of deep brain stimulation may reduce severe, disabling tremor. For those people who responded to treatment, there was an improved quality of life and ability to carry out every day tasks.
Zakaria R, Vajramani G, Westmoreland L, et al.
Tremor reduction and quality of life after deep brain stimulation for multiple sclerosis-associated tremor..
Acta Neurochir (Wien). 2013 Aug 22. [Epub ahead of print]
More about the management of tremor
You can read more about tremor and deep brain stimulation, including other studies with people with MS, in the A to Z of MS. NHS England has issued a clinical policy statement on funding deep brain stimulation (PDF) which does not mention MS but does not appear to exclude it from being funded by the NHS.
There are a number of options for the management of tremor which are less invasive than surgery. They include adapting how you do tasks so that the effect of tremor is minimised. An example would be to deliberately stop before reaching a target object, such as a cup, and then slide the hand forward to grasp it as this can reduce the effect of tremor. An occupational therapist can advise on these kinds of approaches.
Physiotherapy can also help as it can strengthen the core body muscles of the trunk and improve posture which may help with tremor. Drug treatments are not often used but splints or Lycra garments can be helpful.
Research by topic areas...
Kang H, Metz L, Traboulsee A, et al.
Application and a proposed modification of the 2010 McDonald criteria for the diagnosis of multiple sclerosis in a Canadian cohort of patients with clinically isolated syndromes.
Mult Scler. 2013 Aug 22. [Epub ahead of print]
Papais-Alvarenga RM, Vasconcelos CC, Alves-Leon SV, et al.
The impact of diagnostic criteria for neuromyelitis optica in patients with MS: a 10-year follow-up of the South Atlantic Project.
Mult Scler. 2013 Aug 22. [Epub ahead of print]
Quality of life
Vitkova M, Rosenberger J, Krokavcova M, et al.
Health-related quality of life in multiple sclerosis patients with bladder, bowel and sexual dysfunction.
Disabil Rehabil. 2013 Aug 20. [Epub ahead of print]
Causes of MS
Asadollahi S, Fakhri M, Heidari K, et al.
Cigarette smoking and associated risk of multiple sclerosis in the Iranian population.
J Clin Neurosci. 2013 Aug 20. [Epub ahead of print]
Rosti-Otajärvi E, Mäntynen A, Koivisto K, et al.
Patient-related factors may affect the outcome of neuropsychological rehabilitation in multiple sclerosis.
J Neurol Sci. 2013 Aug 9. [Epub ahead of print]
Negahban H, Sanjari MA, Mofateh R, et al.
Nonlinear dynamical structure of sway path during standing in patients with multiple sclerosis and in healthy controls is affected by changes in sensory input and cognitive load.
Neurosci Lett. 2013 Aug 21. [Epub ahead of print]
Kalron A, Dvir Z, Givon U, et al.
Gait and jogging parameters in people with minimally impaired multiple sclerosis.
Gait Posture. 2013 Aug 6. [Epub ahead of print]
Pilutti LA, Dlugonski D, Sandroff BM, et al.
Gait and six-minute walk performance in persons with multiple sclerosis.
J Neurol Sci. 2013 Jul 30. [Epub ahead of print]
Fernandez O, Arnal-Garcia C, Arroyo-Gonzalez R, et al.
Review of the novelties presented at the 28th Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) (I).
Rev Neurol. 2013 Sep 1;57(5):217-229.
Makris A, Piperopoulos A, Karmaniolou I.
Multiple sclerosis: basic knowledge and new insights in perioperative management.
J Anesth. 2013 Aug 21. [Epub ahead of print]